By Anonymous

Within your placement, ask a consultant about a clinical protocol he/she had to follow in the last week. Was there any aspect of the protocol he/she disagreed with? How did the clinician deal with this?

“Tell me about the demons, Gerald.”

A smile spread over the patient’s face at the psychiatrist’s question. The smile was genuine and innocent, and perfectly suited his chubby, childlike face. “Well they’re always around me. They keep me company. Look, there’s some right now,” he said, pointing at the ceiling above the psychiatrist’s head. I fought the urge to look where he was pointing for a moment, but then it overwhelmed me, and I looked up, to see a disappointingly demon free ceiling.

The psychiatrist seemed less interested in entertaining this fantasy and kept his attention squarely on his writing pad. Every now and then the scratching noise his fountain pen made against the paper was overpowered by a screech from the ward. The patient seemed transfixed with how the gleaming nib danced under the down lighting of the interview room.

“Have you told your family about the demons?” questioned the clinician.

“The demons are my family.” The psychiatrist looked up from his writing pad, a disconcerted expression permeating his usually infallible poker face. He hadn’t heard that one before.

“These demons, do they speak to you?” he quizzed. Gerald nodded a content, energetic nod. “Do they ever ask you to hurt yourself?”

“No, Doctor, never.” The psychiatrist went quiet for a moment, tapping the back of his fountain pen against his chin.

“What about other people, do they demons ever ask you to hurt other people?” the psychiatrist changed tact. Gerald nodded a more vigorous, almost violent nod, the smile on his face expanding to the point I was afraid he might swallow his own head.

The psychiatrist’s eyes narrowed. “Gerald, the demons aren’t telling you to hurt me, are they?” Gerald let out an involuntary giggle. The psychiatrist’s gaze flickered towards the door to his right for a brief moment, then returned to Gerald. “What are they telling you to do right now Gerald?”

Between bouts of giggling Gerald stuttered out an answer; “They’re saying to take that silly pen of yours,” his response was punctuated by more erratic laughter, “and stick it in your eye.” As Gerald continued to cackle away the psychiatrist purposefully capped the fountain pen and tucked it securely away inside his suit jacket.

“I think we’ve got everything we need Gerald, thank you for your… candidness,” the psychiatrist drew the interview to a close, and turned to me as Gerald skipped out of the interview room. “Thoughts?”

I hesitated for a moment before offering an uncertain answer, “He’s not reacting to the Clozapine the way we had hoped.”

“So, what do you recommend?” he pushed.

“Maybe we try something else.”

“We have tried almost everything else. Clozapine is the end of the line, it’s for treatment resistant schizophrenia. It’s what we use when nothing else works. We’re kind of stuck now.”

“We could up the dose-”

“And risk agranulocytosis,” my shoulders slumped as I attempted to shrink away into my chair. “It could put an end to the psychosis though,” he offered, and I beamed at my first correct answer all day, “by killing him.”

“Oh,” I sighed.

“We stand behind the TTO,” he said standing up, “There’s not much else we can do at this point.”

“Um, this may sound like a stupid question-”

“There are no stupid questions,” he interjected, “only stupid people.”

“Right.” This was reaching record levels of discomfort. “What exactly is a TTO?”

“A Temporary Treatment Order. Its kind of a measure we use for acutely ill patients, that is patients who are at risk of harming themselves or others if untreated,” he explained, “We can install one provided it is the least restrictive means to ensure safety, and it allows us 28 days in an inpatient facility to form some sort of immediate action plan. For Gerald, I just want more time to see if the Clozapine will take effect, as we are very much in the transition phase between antipsychotics.”

“Uh huh,” I nodded.

“It’s never ideal, but its sometimes necessary. Some patients really deride it, but Gerald’s a relatively agreeable fellow. Violent fantasizations aside, of course,” he clarified as he turned to leave the room and return to the psychiatric ward. After a brief hesitation I followed.